高龄患者胆囊合并胆总管结石治疗方法选择的临床研究

发布时间：2018-05-21 12:35

本文选题：高龄患者 + 胆囊结石　；参考：《天津医科大学》2015年硕士论文

【摘要】：目的:在当今社会,胆道结石发病率呈现明显增高趋势。胆道结石治疗方法虽然很多但对于高龄患者胆囊并胆管结石的治疗瓶颈尚未完全突破,依据现代损伤控制理论如何以最小的创伤和最快的恢复并充分运用微创技术治疗胆石病仍存争议。本研究比较应用传统开腹术治疗与应用现代腔镜微创手术治疗患者的临床疗效等临床资料,观察成功实施单纯开腹手术与双镜联合手术包括腹腔镜联合胆道镜行胆囊切除胆管取石术、内镜联合腹腔镜先行胆管取石而后行胆囊切除术的全部患者的性别、年龄、并存病等一般情况、术前术后血液化验、术后肛门恢复自主排气时限、术后体温波动等生命体征变化、术后腹腔出血、消化道出血等并发症发生率以及术中情况等与手术相关的临床指标,以期能够在制定针对高龄患者胆囊并胆管结石治疗方案时提供参考。方法:收集整理南开医院微创外科自2012年6月至2013年6月住院接受各种胆道手术治疗的900例患者资料,并从所选患者中选取年龄≥70岁且≤85岁的胆囊并胆总管结石的高龄病例108例。按照分别接受不同手术治疗方式将入选的108例病例分成三组,开腹手术A组和微创手术B组、C组,其中开腹A组20例患者成功实施了开腹胆囊切除、胆总管探查取石、T管引流术(OCHTD),微创B组60例患者为腹腔镜联合十二指肠镜即首先施行内镜下Oddi括约肌切开网篮胆总管内取石而后施行腹腔镜胆囊切除术(EST+LC),微创C组28例患者采用腹腔镜联合胆道镜双镜联合术式即在腹腔镜下行胆囊切除、胆总管切开后应用胆道镜网篮取石及T管引流术(LC+LCBDE+IOC)。通过对手术完成所用时间统计,手术过程中失血计量,患者出现术后并发症发生率,以及患者术后生命体征变化、肛门自主排气恢复时间统计,患者术前术后血液化验胆红素、转氨酶、白细胞恢复正常时间计算、住院时长统计等指标进行观察比较,对接受不同治疗胆石症手术方案的三组高龄患者临床资料结果进行统计学分析。结果:1.术前临床资料:三组患者性别、年龄、术前白细胞、血TBIL、DBIL、ALP、ALT、AST、GGT、WBC水平、全身机体状况、心肺功能及内科基础疾病等临床资料相比,均无明显差异(p0.05),可以进行比对。2.术中指标:微创B组完成手术操作所用时限比开腹A组和微创C组完成所用时限显著缩短,手术操作过程中总出血量微创B组比开腹A组和微创C组都显著减少(p0.05);而微创C组完成手术操作所用时限要短于开腹A组完成手术时限(p0.05),而开腹A组在手术操作过程里的出血总量与微创C组手术相比较可以观察到显著增多,有统计学意义(p0.05)。3.术后恢复指标:开腹A组和微创C组手术后早期体温波动和疼痛反应要显著高于微创B组,腹胀不适缓解及肛门自主排气等胃肠道功能恢复时间亦长于微创B组(p0.05);而微创C组胃肠道功能恢复时间则低于开腹A组(p0.05),但三组患者术前血液生化化验比较无显著差异,术后血液生化指标胆红素、转氨酶、碱性磷酸酶、白细胞等降至正常时限所用时间接近,三者比较无明显差异(p0.05)。4.手术疗效和并发症:所有病例手术均成功实施且顺利康复,三组病例手术成功率无差异。开腹A组手术患者中有1例患者出现轻度胆汁渗漏经充分引流等保守治疗5天后停止渗漏,并有1例患者出现切口感染经积极换药治疗后2周内愈合,3例出现肺部感染经积极治疗治愈;微创B组中3例患者在实施EST手术后出现了短暂性血淀粉酶升高并发轻度胰腺炎一周内治愈,1例患者出现少量黑便(胆道出血)经保守治疗恢复;微创C组(LC+LCBDE+IOC组)2例患者出现轻度胆漏均在一周内治愈,三组病例A组术后并发症发生率较BC两组增高(p0.05),而BC两组比较无显著差异(p0.05)。5.住院时间:统计比较患者总住院天数和各组平均住院天数以及术后住院天数后发现,开腹A组与微创C组患者平均住院日均比微创B组显著增多、尤其术后住院时间明显延长,开腹A组与微创C组术后平均住院日比B组均显著增加(p0.05);而开腹A组与微创C组两组之间相比总住院天数相近,术后拔除T管至完全康复所用时间接近,无显著差异(p0.05)。结论:1.年龄大于70岁的高龄胆石症患者,胆囊并胆总管结石,尤其当出现胆囊炎合并胆管炎时病情急进展迅速,为能够迅速阻断胆系感染发展至重度感染治疗原则应力求安全、快速、简单、高效。由于EST+LC双镜联合方案已广泛应用经过实践证明较为安全,并且具有诸多优点,可以最大限度的降低对患者的腹部损伤并可为患者带来心理上的宽慰,能够有效的降低因开腹手术造成的肠粘连等手术并发症,术后胃肠功能早期恢复可尽快恢复饮食、缩短住院时间相应减轻了患者负担,故治疗高龄胆石病患者时可作为首选方案。2.而LC+LCBDE+IOC比传统开腹手术术后恢复上具有优势,腹部创伤小、术后胃肠功能恢复较快、肠粘连发生率低等优势,该方案具有相应应用空间,但由于该术式要求患者能够耐受气腹、胆管结石直径较小等严格条件,故需注意掌握相应临床适应症。虽然微创双镜联合技术越来越广泛应用于临床,但因其存在相应局限性,故传统开腹手术仍然是微创技术的基础及坚强后盾。
[Abstract]:Objective: in today's society, the incidence of cholelithiasis is obviously increased. Although there are many methods for the treatment of cholelithiasis, the treatment bottlenecks of gallbladder and bile duct stones in elderly patients have not been completely broken. According to modern damage control theory, how to treat cholelithiasis with minimal trauma and quickest recovery and minimally invasive technique is still used to treat cholelithiasis. This study compared the clinical data of traditional open abdominal surgery and the application of modern endoscopic minimally invasive surgery to treat patients. The successful implementation of simple open laparotomy and double mirror combined operation including laparoscopic cholecystectomy choledochectomy with choledochoscopy, endoscopic combined laparoscopy and bile duct stone removal and biliary drainage All patients' sex, age, coexistence of disease and other general conditions, preoperative and postoperative blood tests, postoperative anus recovery time limit, postoperative body temperature fluctuations and other life signs, postoperative abdominal bleeding, digestive tract bleeding and other complications, as well as the operation related clinical indicators, in order to be able to be formulated. In order to provide reference for the treatment of gallbladder and bile duct stones in elderly patients. Methods: the data of 900 patients who were hospitalized from June 2012 to June 2013 were collected and treated in Nankai hospital from June 2012 to June 2013, and 108 elderly cases aged 70 years old and less than 85 years old were selected from the selected patients. 108 cases were divided into three groups according to the different surgical treatment methods, A group and B group of minimally invasive surgery, group C, of which 20 patients in group A were successfully operated on open cholecystectomy, choledocholithotomy, T tube drainage (OCHTD), and minimally invasive B group, and the laparoscopy combined with duodenoscopy was the first endoscopy. Laparoscopic cholecystectomy (EST+LC) was performed in the lower Oddi sphincterotomy net basket choledochus, and 28 patients in the minimally invasive C group were performed laparoscopic cholecystectomy with laparoscopic combined choledochoscopy combined operation. The choledochoscope was used to remove stones and T tube drainage (LC+LCBDE+IOC) after common bile duct incision. The operation was completed by the operation. Time statistics, blood loss in the operation, the incidence of postoperative complications, and the changes in the life signs, the recovery time of the anus, the blood test of the patients before and after the operation, the blood test of bilirubin, the aminotransferase, the normal time of leukocyte recovery, and the length of the hospital. The clinical data of three groups of elderly patients treated with cholelithiasis were analyzed statistically. Results: 1. clinical data before operation: three groups of patients' sex, age, preoperative leukocyte, blood TBIL, DBIL, ALP, ALT, AST, GGT, WBC level, body condition, cardiopulmonary function and basic diseases of internal medicine, no significant difference (P0.05) Compared with the.2. group, the time limit used in the minimally invasive B group was significantly shorter than that of the open A group and the minimally invasive C group. The total bleeding volume of the B group in the operation process was significantly lower than that of the open A group and the minimally invasive C group (P0.05), while the minimally invasive C group completed the operation of the hand operation shorter than the laparotomy A group. Time limit (P0.05), and the total amount of bleeding in the operation A group was significantly higher than that of the minimally invasive C group, and there was a statistically significant (P0.05) recovery index after.3.: the early temperature fluctuation and pain response of the open A group and the minimally invasive C group were significantly higher than the minimally invasive B group, abdominal distention remission and anus autonomic exhaust. The recovery time of gastrointestinal function was also longer than that of the minimally invasive B group (P0.05), while the recovery time of gastrointestinal function in the minimally invasive C group was lower than that of the open A group (P0.05), but there was no significant difference between the three groups before the operation, and the time of blood biochemical indexes of bilirubin, aminotransferase, alkaline phosphatase and white blood cells was close to the normal time limit, three There was no significant difference (P0.05) in the curative effect and complication of.4. operation: all cases were successfully implemented and recovered successfully. There was no difference in the success rate of the three cases. In the open A group, 1 cases had mild bile leakage through adequate drainage and other conservative treatment for 5 days. 2 weeks after the treatment, 3 cases of pulmonary infection were cured by active treatment, and 3 patients in the minimally invasive B group had transient blood amylase elevation and mild pancreatitis within one week after EST operation, and 1 cases had a small amount of black stool (biliary tract bleeding) recovered by conservative treatment; and 2 patients in the minimally invasive C group (group LC+LCBDE+IOC) were produced. The current mild bile leakage was cured within one week. The incidence of postoperative complications in the three group A group was higher than that in the BC two group (P0.05), while the BC two groups had no significant difference (P0.05).5. hospitalization time: the statistical comparison of the total hospital days, the average days of hospitalization and the number of postoperative hospitalization days, and the average daily average hospitalization of the open A group and the minimally invasive C group were found. Compared with the minimally invasive B group, especially after the operation, the hospitalization time was obviously prolonged. The average hospitalization days in the open A group and the minimally invasive C group were significantly higher than those in the B group (P0.05), while the total hospitalization days were similar in the open A group and the minimally invasive C group between the two groups. There was no significant difference (P0.05) when the T tube was removed to the complete recovery after the operation (P0.05). Conclusion: the 1. age is more than 70. The elderly gallstone patients, gallbladder and choledocholithiasis, especially when cholecystitis and cholangitis occur rapidly, should be safe, fast, simple and efficient for the rapid blocking of the development of biliary infection to severe infection. Since the EST+LC double mirror combination scheme has been widely used in practice, it has been proved safer and more safe. With many advantages, it can reduce the abdominal injury to the patient to the maximum and bring psychological comfort to the patient. It can effectively reduce the complications such as intestinal adhesion caused by laparotomy. The early recovery of gastrointestinal function after the operation can restore the diet as soon as possible, shorten the hospital time and reduce the burden of the patients accordingly. Therefore, the treatment of the elderly is in the age of age. Patients with cholelithiasis can be selected as the first choice.2. and LC+LCBDE+IOC has advantages over the traditional open operation, the abdominal trauma is small, the recovery of gastrointestinal function is faster and the incidence of intestinal adhesion is low. The scheme has the corresponding application space, but the patient can tolerate the pneumoperitoneum, the diameter of the bile duct stone is smaller and so on. It is necessary to pay attention to the corresponding clinical indications. Although the combination of minimally invasive and double mirrors is becoming more and more widely used in the clinic, the traditional open abdominal surgery is still the foundation and strong backing of the minimally invasive technique because of its limitation.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R657.4

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